dental benefits for adults, including exams, preventive services, and restorative … · 2019. 8....

Technical Proposal 2.10.3 Enrollee Value Added Benefits

LDH RFP #:3000011953 | 2.10.3 – 1 of 15 |

2.10.3 Enrollee Value-Added Benefits

2.10.3.2 The Proposer should identify whether it proposes to offer any of the following six (6) optional value-added benefits to its enrollees.

Humana will offer all six of the optional Value-Added Benefits (VAB) to our Louisiana Medicaid enrollees. Additionally, we will provide transportation services to and from all visits and appointments related to the VAB, thereby reducing barriers to health and social services.

We have designed our VAB for Louisiana to align with LDH’s goals of achieving better health, better care, and lower costs, while promoting preventive care, reducing emergency department (ED) visits and hospitalizations, and improving enrollees’ overall experience. These benefits are specially tailored to fit within our person-centered care model to ensure we inform enrollees and guide them to the services available to meet their needs. Humana trains all Medicaid enrollee-facing associates on VAB, making these benefits readily accessible to every enrollee. In addition, our Go365 enrollee incentive platform will enhance the VAB experience by providing enrollees near real-time rewards for completing healthy behaviors, such as dental visits and smoking cessation counseling. Go365 is deeply rooted in behavioral economics and actuarial science, and will support enrollees live healthier and reduce healthcare costs by integrating rewards with positive behavior.

In addition to the six VAB defined by the Contract, Humana will work closely with LDH on an ongoing basis to identify and offer additional innovative VAB that will improve the health outcomes of Louisiana’s Medicaid population. We will submit any additions, deletions, or modifications to LDH for approval at least six months in advance of the effective date, in accordance with Section 2.5.5.4 of the Model Contract.

1 Dental benefits for adults, including exams, preventive services, and restorative services, but excluding extractions;

Humana’s comprehensive dental benefits will improve enrollees’ dental health and hygiene and increase access to dental services across the State. Aligning with the American Dental Association’s (ADA) policy emphasizing the importance of regular dental visits to maintain optimal oral health, our benefits will enable Louisiana’s adult population to maintain good oral hygiene and seek services at the right time and in the right setting.

To encourage enrollees to utilize this benefit, we will reward those who complete a dental visit with a $10 gift card to a retailer of their choice via our Go365 Mobile Member Incentive Application.

Recognizing that coverage alone does not ensure care will occur, Humana will provide transportation to and from dental visits for all enrollees to facilitate and improve access to dental care.

2.10.3.3.1 The populations who may receive the benefit;

Adults aged 21 and older will be eligible for Humana’s value-added dental services.

2.10.3.3.2 The scope of the benefit, including procedure codes, descriptions where applicable, and how the scope compares to existing Louisiana Medicaid coverage;

Scope: Value-added dental benefits include annual preventive services, exams, and restorative services (excluding extractions) for the procedure codes listed below, up to a $1,000 annual allowance. Humana’s comprehensive dental benefits include but are not limited to cleanings, Silver Diamine Fluoride treatment, bitewings, fillings, specialized care in emergencies, and crowns.

Procedure Codes and Description: • Dental Services: Procedure codes D0120, D0140, D0150, D0190, D0191 , D0210, D0220, D0230, D0240, D0250,

D0251, D0270, D0272, D0273, D0274, D0330, D1110, D1206, D1208, D1330 , D1354, D2140, D2150, D2160,D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394, D2740, D2750, D2751 , D2752,

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D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D9110, D9920 (limited to patients with special needs)

• Biannual $10 Gift Card: Enrollees will also be eligible to receive a $10 gift card twice a year upon completingbiannual dental visits to incentivize good oral health.

Comparison to Existing Louisiana Medicaid Coverage: Humana’s dental benefits expand coverage to adults aged 21 and over. Under Louisiana’s existing coverage, this population has no covered dental services for the procedures listed above, other than emergency procedures administered in an ED.

2.10.3.3.3 Any proposed co-payments;

Humana’s dental VAB does not require co-payments.

2.10.3.3.4 How the benefit will be provided to enrollees, including, if provided through a subcontractor, either the selected subcontractor or description of how the subcontractor shall be selected; and

Enrollees can access dental VAB at any point, without a referral or prior authorization. We will describe this benefit in all relevant member materials and recommend it during interactions between enrollees and our case management and Member Service representatives (MSRs). Recognizing the critical role that providers play in counseling our enrollees about dental health, we will offer provider education on our dental VAB and materials for them to share with our enrollees. Enrollees and providers will learn more about dental benefits via welcome calls, a flyer mailed to the enrollee’s home detailing Humana’s VAB, the Enrollee Handbook and Provider Handbook, the Provider Training Manual, through interactions with Humana Case Managers (CMs), the Humana website, provider training events, newsletters, at local Humana offices, and at community events.

We will provide dental services through a subcontracted agreement with DentaQuest. Humana selects subcontractors with longstanding and significant experience in their fields; we have partnered with DentaQuest for 13 years to bring dental coverage to more than 300,000 Medicaid enrollees.

Together with its affiliates, DentaQuest will provide network development, network management, quality management, and program administration, including provider contracting, credentialing, claims processing and payment, enrollee and provider services, utilization management (UM), and reporting. In Louisiana, DentaQuest currently contracts with more than encompassing general practitioners and the six specialty areas of endodontists, oral surgeons, orthodontists, pediatric dentists, periodontists, and prosthodontists. DentaQuest’s network also exceeds the requirements of one provider in every 30 miles with three dental options within less than nine miles.

2.10.3.3.5 How the Proposer will provide oversight of the value-added benefits.

Benefit Management Continuous evaluation and reporting helps Humana ensure that our enrollees utilize our VAB effectively and that they meet quality standards. Our Medicaid Product Development Lead will coordinate with assigned VAB vendors and effectively manage the relationship. Additionally, we will present VAB performance data, utilization metrics, and derived outcomes to the Louisiana local Market Operating Committee (LMOC) meetings. The LMOC comprises market leadership, subject matter experts (SMEs), and corporate partners. The LMOC will assess and review monthly reports drafted by Product Lead on utilization of the dental VAB against all identified enrollees to ensure we notify all eligible enrollees of these services. The committee will review utilization results, identify trends of high and low utilization, and note possible process improvements. The LMOC also oversees the Provider and Member 360 Committees.

Subcontractor Oversight The Subcontractor Oversight team provides monitoring and oversight of all material subcontractors via monthly Subcontractor Performance Summary Reporting. This reporting captures all audit results, performance measure results including LDH performance requirements, status on any open Corrective Action Plans (CAPs), and other key issues and opportunities. The Subcontractor Oversight team also identifies issues and opportunities meriting review and consideration within the quarterly Subcontractor Oversight Committee meetings and, as appropriate, by the Quality Improvement Committee (QIC). During these meetings, we will discuss utilization of dental services and

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activities to promote access. Humana’s Subcontractor Oversight team and UM team partner to oversee the administration of dental VAB. Together, the teams design utilization measures and reporting details at the onset of the Contract and on a regular basis to ensure enrollees are accessing services. We report DentaQuest performance and enrollee utilization of benefits weekly.

2 Evidence-based non-pharmacologic alternatives to opioids for chronic pain management services for adults

Our pain management VAB will offer numerous evidence-based non-pharmacological measures to address chronic pain and provide alternatives to opioids. Humana’s non-pharmacological alternatives align with the CDC Principles for Chronic Pain Treatment’s recommended evidence-based alternatives for chronic pain conditions. To ensure access to our pain management services, Humana will cover transportation to and from appointments and services for all enrollees.


Understanding the negative long-term impacts that opioids can cause, we will offer our VAB to any enrollee with chronic pain to prevent opioid use and to support those using opioids with non-pharmacological alternatives where medically appropriate. Enrollees 21 and older suffering from chronic pain and/or opioid use disorder can take advantage of unlimited (up to 365 times per service per year) services for acupuncture, chiropractic, and massage therapy, and are also eligible to receive gym memberships for exercise therapy. Enrollees younger than 21 years of age can access these benefits with prior authorization. Humana will offer a home-delivered exercise kit and access to our Go365 health and wellness mobile application, accessible to all enrollees between 16 and 21 years old with parental consent. We will refer enrollees under 21 to chiropractic services under Louisiana Medicaid covered services.


Scope: Humana’s numerous VAB provide a wealth of non-pharmacological opioid use alternatives for our enrollees experiencing chronic pain. Our pain management benefits include unlimited acupuncture, chiropractic, and massage therapy, methods proven to relieve discomfort by releasing endorphins and stimulating nerves that mute pain signals. Enrollees can also qualify for a fully-paid gym membership. An enrollee’s CM can request exercise kit deliveries. Humana further engages enrollees through our Go365 mobile application to encourage and incentivize enrollees to complete health and wellness activities.

Procedure Codes and Description: • Acupuncture: Procedure codes 97810, 97811, 97813, 97814, 97010, 97112, 97140• Chiropractic: Procedure codes 98940, 98941, 98942, 98943• Massage Therapy: Procedure code 97124• Exercise Kit Delivery: Mailed directly to a qualifying enrollee’s home every three years, our exercise kit includes a

yoga mat, a Bluetooth-enabled pedometer, and an exercise manual that includes quick and easy at-homeworkouts and yoga poses, as well as a list of where to find more resources on how to stay active without needingto leave home.

Comparison to Existing Louisiana Medicaid Coverage: Humana has designed its pain management VAB to provide additional paths to deter the use of opioids for pain management and help enrollees already using opioids for pain management to decrease their dependence. Our VAB will complement and increase the availability of covered services that can help enrollees manage pain, including cognitive behavioral therapy and chiropractic services for enrollees under 21.


Humana’s non-pharmacological alternatives to opioids for chronic pain management VAB does not require co-payments.

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Humana proactively identifies enrollees at risk of being addicted or addiction to opioids. Our Opioid Task Force, composed of clinical leaders from medical, behavioral health (BH), and pharmacy offices, ensures that enrollees with chronic pain receive appropriate, evidence-based treatment. We also leverage technology to reduce inappropriate utilization of prescription opioids. Humana’s owned pharmacy benefits manager (PBM), Humana Pharmacy Solutions, reduces opioid overuse and abuse using drug safety edits designed to ensure that opioids are prescribed in a manner consistent with clinical practice guidelines. Drug safety edits provide real-time safety checks to identify enrollees receiving opioid prescriptions from multiple prescribers, those receiving more than one opioid or multiple drug strengths, and drug-to-drug interactions that pose a potential health risk. These edits have proven to be a significant and effective tool in safely managing a patient’s opioid exposure.

. Enrollees identified through these mechanisms will receive case management to engage the enrollee in care, including covered services and our VAB, to support the enrollee in finding effective non-pharmacological alternatives. Our approach to engaging enrollees is three-fold:

1. Provider Education: Upon identifying enrollees with painmanagement, Humana immediately reaches out to providers prescribing opioids and engages them in educationon alternative treatment modalities. Through our integrated BH and pharmacy offering, when providersprescribe opioids exceed dosage and quantity requirements and enrollees subsequently attempt to fill theseprescriptions, Humana’s edits will reject the ability for the pharmacy to fill the order. We follow the reject withoutreach from our team to inform the provider of alternative treatment mechanisms, including non-pharmacological alternative treatments for pain management. Humana provides routine reports of sharedenrollees/patients identified as needing support in managing chronic pain. Humana also monitors all providersthat prescribe opioids and identifies opportunities to educate providers where alternative treatment is clinicallyappropriate. Humana is actively engaged with physicians to prevent opioid overuse and abuse by: (1) providingphysicians with information about their patients that they may not otherwise have access to, such as patientsbeing treated by multiple prescribers, filling prescriptions at numerous pharmacies, and/or receiving high dosesof opioids and (2) providing information to physicians to aid in their clinical decision-making, including clinicalguidelines for tapering opioids. Using these mechanisms, we proactively engage with and educate providers,encouraging the use of our evidence-based alternatives instead of continued opioid use, where medicallyappropriate.

2. Care Management Education: Humana’s Care Management department will offer our VAB to eligible enrolleesand include information on their effectiveness and how to access them. We will educate enrollees identified forchronic pain management by their provider on the covered services and VAB available to them through high-risk/priority population care management program. We will also educate providers on making referrals to ourcare management department to ensure all enrollees identified by their providers for alternative painmanagement therapies receive the VAB. The CM will convene a multi-disciplinary care team (MDT) to develop anindividualized care plan to ensure utilization of all appropriate covered services and supportive VAB. The MDTwill assess the enrollee’s chronic pain diagnosis, ongoing pain history, evidence of using physical therapy oroccupational therapy to manage pain, or a note from the enrollee’s primary care provider (PCP) recommendingregular exercise or other value-added treatment modality, including unlimited acupuncture, chiropracticservices, massage therapy, and six months of gym membership that can be reapproved based on enrolleeengagement. CMs also ensure enrollees confirm with their PCP that exercise would be a safe and effective painmanagement treatment. The CM will engage with the enrollee monthly, ensuring they educate on how tomaximize the covered benefits and our VAB, that the enrollee is engaged in care and regularly checking in withtheir PCP to treat their chronic pain needs, and has an overall understanding of how to access healthcare

Humana’s Drug Utilization Review program received the

“Best Practice Award for Quality Improvement in Continuity of Care” by the NCQA for coordinating care

in prescribing opioids across multiple settings.

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services appropriately. As the enrollee demonstrates ongoing engagement with their PCP and covered services, they will continue to receive VABs we offer. CMs can also request home delivery of an exercise kit, which includes a Bluetooth-enabled pedometer, a yoga mat, and a simple at-home exercise guide, ensuring that enrollees without access to a gym have the tools they need to become their healthiest selves.

3. Enrollee Education: Humana’s Enrollee Handbook and other member materials (available in print, online, or onour MyHumana mobile application) offer a comprehensive description of all covered services and VAB we offer.Enrollees may call our Member Services Call Center or their CMs to receive more information. Additionally,Humana engages enrollees using patient education videos and education through Humana Pharmacy at the timeof the prescription fill. On the first fill of an opioid prescription, we email enrollees a patient education video thatprovides information on opioids and the specific medication, including side effects, storage, disposal, and risk ofaddiction and overdose.

As part of our person-centered care model and approach, our local associates will identify programs available to our enrollees and connect them with community resources.


Benefit Management Continuous evaluation and reporting ensures that our enrollees utilize our VAB effectively and that they meet quality standards. Our Medicaid Product Development Lead will coordinate with assigned VAB vendors and effectively manage the relationship. Additionally, we present VAB performance data, utilization metrics, and derived outcomes at LMOC meetings. The LMOC comprises market leadership, SMEs, and corporate partners. The LMOC will assess and review monthly reports drafted by the Product Lead on utilization of the non-pharmacological pain management VAB against all identified enrollees with opioid use disorder to ensure we notify all eligible enrollees of these services. The committee will review utilization results, identify trends of high and low utilization, and note possible process improvements. The LMOC also oversees the Provider and Member 360 Committees. The Member 360 Committee will identify process improvement opportunities to ensure the VAB support our enrollees. Our Provider 360 Committee meetings will identify processes to educate and encourage providers to refer enrollees to the VAB.

3 Respite care model is targeting homeless persons with post-acute medical needs. The model shall address strategies for counseling, nutrition, housing stabilization, transitional care, and other services necessary for successful community reintegration;

Humana has developed a comprehensive medical respite program to support our homeless enrollees with post-acute medical needs. Our three primary goals are ensuring enrollee recovery and stabilization, successful enrollee integration back into the community, and reducing unnecessary ED stays and visits. Conversations with Community-Based Organizations (CBOs) across the nation experienced in providing medical respite care as well as the advice of leading experts in this field, such as the National Health Care for the Homeless Council, inform our strategy. We have engaged with local Louisiana homelessness services providers to begin developing partnerships for our medical respite care program and Humana’s broader homelessness diversion strategy

and have designed our VAB with learnings from these community leaders. These meetings affirmed the need for and utilization of a housing-first approach, as stable housing serves as the foundation for the achievement of medical, BH, and personal goals.

The following section describes our approach to the medical respite program, including the population who may participate in the program, the program’s scope, how we will provide benefits, and how Humana will provide oversight.


Enrollees who are 18 and older experiencing homelessness or at-risk for homelessness with a post-acute medical need will be eligible to receive this VAB.

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We will identify eligible enrollees during the discharge planning process at hospitals. Enrollees are also eligible for medical respite if identified by a family member, PCP, or other community network members and if determined medically necessary. Humana will educate our hospital network and our UM coordinators, who are responsible for discharge planning, on the availability of the program, the eligibility criteria, and the referral process. Our UM coordinators, in turn, will notify our CMs of the admission and referral for medical respite. If the enrollee is not yet engaged in case management, we will invite them to participate as an enrollee with special healthcare needs.

when an enrollee known to be homeless and engaged in case management is hospitalized.

Identifying Enrollees Who Are or At Risk for Homelessness. Understanding the negative downstream impact of homelessness on health, we have designed a multi-pronged approach to identify enrollees who are or are at risk for homelessness in addition to our medical respite program. This includes, but is not limited to, identifying enrollees at risk during the completion of a Health Needs Assessment

When enrollees are identified as homeless, we (together with our partners) will communicate about available services including our VAB, such as medical respite.

This relationship also includes identifying enrollees who return to the community from incarceration based on data sent from the State as well as data transmitted from the Corrections-Community Care Continuum (GC4) through the Greater New Orleans Health Information Exchange (GNOHIE) to use as a second source of data to identify these enrollees. Lastly, Humana recognizes the State’s investment in building infrastructure to identify and track housing capacity and homeless individuals through the Homeless Management Information System (HMIS). to identify our enrollees at risk while protecting enrollee privacy.


Humana has designed its strategy for medical respite to proactively identify and engage enrollees with the support needed for a successful recovery and community reintegration. As part of this strategy, we will offer medical respite beds for homeless enrollees as a safe place to recover from illness, as well as a Medical Flexible Stabilization Support Fund that will provide monetary support, at the discretion of the CM, to assist the enrollee’s transition to a stabile and more permanent setting.

Medical Respite Service. Our program will offer post-acute medical respite beds with evidenced-based low-barrier medical care that will be covered for up to 89 days and at a rate of up to $250 per night per enrollee per year. We have modeled a comprehensive medical respite program based on learnings from best-in-class programs that have demonstrated measurable impact. Humana’s medical respite program will produce a positive impact on LDH’s priority measures, including potentially preventable readmissions and ED visits. Similar medical respite programs have achieved a 50% reduction in 90-day readmissions, 50% reduction in hospital stays following respite, and significant cost avoidance for hospitals partnering with medical respite programs. Additionally, our model incorporates national best practices for medical respite, ensuring a local approach for effective partnerships and providing appropriate flexibility for providers and enrollees to enable effective outcomes. • Wraparound Services: We will tailor the rate paid per night for respite services to the needs of the enrollee as

well as the capacity of the contracted CBOs to provide wraparound services. These wraparound services includebut are not limited to: low-barrier post-acute medical and BH care, medication management, chronic diseasemanagement, meals, and health education. The rate paid per night for respite services will vary depending onthe provider’s included package of services. For example, providers who provide only a bed will be paid a lowerrate, while providers who directly provide BH counseling will receive a higher rate. We will determine the lengthof stay through an assessment of diagnosis at discharge, the facility providing care, and the assigned CM.Additionally, we will incent our CBOs to include wraparound services that promote long-term stability, including

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education, skills and independence training, and transitions to long-term housing to increase the likelihood of preventing future homelessness.

• Length of Stay: We will determine by medical necessity as determined by the UM coordinator. The length of staywill ensure that the enrollee has enough time to successfully recover from the acute medical need and transitioninto Rapid Rehousing. Humana case management will support efforts to transition enrollees into RapidRehousing or Permanent Supportive Housing based on need

Medical Transitional Support Fund: This fund’s purpose is to ensure that enrollees can successfully transition into permanent housing and to provide financial support that will cover minor barriers to stable living and improved health. This fund is in addition to the cost of the medical respite bed stay and transportation provided to facilities and activities related to medical respite. Humana will provide enrollees with up to $1,800 per enrollee per year with a cap of $3,600 per lifetime, which can be used for services that include, but are not limited to:

Housing Stabilization Nutrition Successful Community Reintegration One-time security deposit for housing, utility bill, household goods, legal aid,

and eviction diversion services

Food vouchers, gift cards to grocery stores, nutrition or

cooking classes

GED classes, education or job skills training, YMCA membership, budget

management classes

We will design the fund and complementary support plan individually with the CM, housing specialist, and each enrollee. These paid-for items will be tracked over time to determine health outcomes for paid services.

Comparison to Existing LA Medicaid Coverage: When a Humana enrollee is deemed eligible and enrollee consent is completed for medical respite bed, we will conduct a comprehensive case management assessment as well as the VI-SPDAT to determine an individual’s needs and eligibility for social services programs. Humana will incent CBOs providing covered medical services during the medical respite stay to use our web-based Availity platform to submit those encounters. Additionally, the Medical Transitional Support Fund will complement the already covered services, seeking to fill in gaps where Medicaid or State Services cannot cover needed items.

Humana’s Housing Specialists will use existing pathways and resources through the State Medicaid Department as well as its sister agencies, including but not limited to, the Housing and Urban Development (HUD) agency, local housing authorities, and Continuum of Care Agencies. Through this process, we will ensure eligible enrollees receive proper and complete care during their hospital stay and transition them to a medical respite bed with appropriate clinical supports.


Humana’s Respite Care Model VAB does not require co-payments.

2.10.3.3.4 How the benefit will be provided to enrollees, including, if provided through a subcontractor, either the selected subcontractor or description of how the subcontractor shall be selected;

Humana will not directly subcontract our medical respite program; instead we will partner with CBOs to provide medical respite beds. We will provide a comprehensive and targeted set of services to each medical respite enrollee, structured to meet that enrollee’s specific needs and to ensure a successful transition into stabilized living. The delivery of our proposed benefit considers provider availability, which differs in urban and rural geographies. In urban areas including New Orleans, Baton Rouge, Shreveport, and Lake Charles, we will offer medical respite in a centralized location with medical, BH, nutrition, and wraparound services provided on-site. Respite in non-urban areas of Louisiana will be coordinated through our partnership with the Louisiana State Balance of Continuum of Care Organizations. We will leverage the Continuum of Care’s regional partners and strong referral networks, which offer a comprehensive suite of services through their local network of faith-based organizations.

Humana will ensure each enrollee has an intake assessment upon acceptance and agreement to participate in a medical respite program. This intake assessment will determine high/medium/low need. The results of that

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assessment will map to a targeted set of services based on this identified need. This mapping will provide a guide of parameters to the CBO providing medical respite beds. If the CBO determines that the individual needs higher-intensity services than initially assessed, they will notify Humana so we can consult with the CBO, discuss the need for additional benefits, and consider alternatives for care settings.

Through a shared decision-making process, CMs and Housing Specialists will promote responsibility and a sense of ownership as enrollees work toward long-term housing. As enrollees engage with our case management program, we will develop a housing stabilization plan with the immediate objective of connecting to community services and a long-term objective of permanent housing. This is where Humana will use the Medicaid Flexible Stabilization Support Fund to provide temporary financial support to assist enrollees with their unique needs.

A comprehensive VAB for individuals experiencing homelessness requires a steady supply of available providers. As we build strong relationships with community partners, we understand that consistent funding streams are a vital concern, with direct implications for the number of enrollees they can serve. As such, Humana will support capacity-building efforts

nd will continue to offer interested and willing organizations performance contracting models, as described in the 2.10.4 Population Health.

The needs of our homeless enrollees do not end after the medical respite period. We will work with our community partners to continue to support the unique needs of homeless enrollees to ensure stabilization and improved health outcomes.

2.10.3.3.5 How the Proposer will provide oversight of the Value-Added Benefits.

Humana regularly monitors the utilization of our VAB. As we identify any enrollee who is homeless or at-risk for being homeless, our CMs and Housing Specialists will attempt to reach out to identified enrollees who are not accessing their value-added and covered benefits to their fullest potential, leveraging relationships with local community organizations and deploying our local associates. We will also automatically notify our CMs and Housing Specialists when the enrollee has missed a regular screening or check-up. We will analyze claims data and clinical insights from CMs to evaluate both short- and long-term outcomes. Humana will consistently review encounter data to ensure continued positive outcomes to enrollees, recommended improvements to maximize impact, and validate the success of the VAB.

Our oversight of CBOs providing medical respite will include regular review of the length of stay requested for individual respite enrollees to ensure the length of stay is appropriate to the acute medical needs. Humana will determine appropriateness and approve referrals to respite. Additionally, we will develop mechanisms to qualitatively ensure that providers deliver promised services and maintain quality.

Continuous evaluation and reporting helps Humana ensure that enrollees utilize our VABs effectively and that they meet quality standards. Our Medicaid Product Development Lead will coordinate with assigned VAB vendors and effectively manage the relationship. Additionally, we present VAB performance data, utilization metrics, and derived outcomes to the LMOC meetings. The LMOC comprises market leadership, SMEs, and corporate partners. The LMOC will assess and review monthly reports drafted by Product Lead on utilization of medical respite beds for homeless enrollees to ensure we notify all eligible enrollees of these services. The committee will review utilization results, identify trends of high and low utilization, and note possible process improvements. The LMOC also oversees the Provider and Member 360 Committees.

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4 Newborn circumcision benefits;

Humana will encourage circumcision procedures during the delivery stay to ensure timely access. Aligning with the American Academy of Pediatrics (AAP) policy that the health benefits of circumcision outweigh its risks, Humana will encourage and offer the circumcision procedure for all newborn enrollees. Through our case management and enrollee education strategies, our Florida Medicaid plan provided circumcision in the first month of life to 98% of enrollees.


Enrollees can receive the circumcision VAB up to age one. We will cover circumcision for enrollees older than one when medically necessary.


Scope: The circumcision VAB covers the circumcision procedure for all newborns up to age one or as medically necessary.

Procedure Codes and Description: Circumcision: Procedure codes 54160, 54150, 54161 (for older than 28 days).

Comparison to Existing LA Medicaid Coverage: Current coverage only includes circumcision as an emergency procedure.


Our newborn circumcision benefit does not require any co-payments.


Enrollees can use the circumcision VAB without referral or prior authorization up to age one. Through our MomsFirst maternity care management program, community baby showers, and other outreach during the prenatal period, Humana will educate all our expecting mothers and families of the circumcision VAB to promote the completion of the procedure during the delivery stay. Enrollees who opt not to utilize the circumcision benefit immediately following delivery can take advantage of our circumcision benefit after one year of age if medically necessary. Humana will also educate our OB/GYNs of our VAB and will work with hospitals to encourage the delivery of this benefit prior to one year of age and after delivery, when appropriate.


Humana regularly monitors utilization of our VAB. Regular reports will analyze utilization of the benefit during the delivery stay, by hospital, and by provider group. Continuous evaluation and reporting helps Humana ensure that enrollees use our VABs effectively and that they meet quality standards. Our Medicaid Product Development Lead will coordinate with assigned VAB vendors and effectively manage the relationship. Additionally, we present VAB performance data, utilization metrics, and derived outcomes to the LMOC meetings. The LMOC comprises market leadership, SMEs, and corporate partners. The LMOC will assess and review monthly reports drafted by Product Lead on utilization of the circumcision VAB against all identified enrollees to ensure we notify all eligible enrollees of these services. The committee will review utilization results, identify trends of high and low utilization, and note possible process improvements. The LMOC also oversees the Provider and Member 360 Committees.

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5 Tobacco cessation benefits, not including medications

Tobacco use among both adults and youth in Louisiana is significantly higher than national averages, costing the state millions each year in ED visits. It is also the leading cause of preventable deaths among adults according to the CDC’s STATE System. The prevalence of e-cigarettes, most notably in middle and high schools, has become a gateway to tobacco use for teens and has backtracked recent measures that had lowered nicotine rates across the State, according to the CDC’s Report on Tobacco Use Among Middle and High School Students. Humana’s evidence-based tobacco cessation program will work in tandem with state offerings, enhancing both coverage and benefits of LDH’s current programs. Core to our approach is identifying all enrollees who smoke and engaging them with the supports they need, including engaging with a provider credentialed by the Smoking Cessation Trust. We will maintain a roster of all enrollees who smoke and continually reach out to those who may not be ready to quit smoking to encourage healthy behaviors and ensure they are aware of the supportive resources available to them. Our benefits align with the CDC’s Best Practices for Comprehensive Tobacco Control Programs, which states that both frequent counseling sessions and financial incentives are key components of a comprehensive and effective smoking cessation program. To ensure access to smoking cessation services, Humana will cover transportation to and from counseling appointments for all eligible enrollees.


We have designed our smoking cessation program for enrollees 12 and above to combat not only adult tobacco use, but also the high vaping rates prevalent among teens in middle and high schools across the State.


Scope: Humana’s VAB include unlimited PCP coaching and counseling for all enrollees 12 and older, a $25 gift card twice per year upon proof enrollees are actively trying to quit, and access to the Craving To Quit innovative and evidence-based smoking cessation program and resources. As part of our smoking cessation VAB program, we will coordinate with services available through the State. This includes services available through the Smoking Cessation Trust for our enrollees who started smoking before September 1988. For pregnant enrollees, Humana will encourage them to utilize covered cessation counseling and offer the gift card incentive and Go365 mobile application.

Procedure Codes and Description: • PCP counseling: Procedure codes 99406, 99407, S9075, S9453, G0375, G0376, 99078• Biannual $25 Gift Card: Enrollees will receive a $25 gift card twice per year upon proof they are actively engaged

in cessation services and trying to quit smoking.• Craving To Quit: This is a 21-day mindfulness-based wellness program based on a successful smoking cessation

curriculum developed and tested at Yale University, and proven to be twice as effective as leading quit smokingtherapies. This evidence-based tobacco cessation program delivers treatment on mobile devices and the Webthrough videos, animations, in-the-moment exercises, and an online support community.

Comparison to Existing LA Medicaid Coverage: Our tobacco cessation VAB will expand coverage and services to all enrollees 12 and over to effectively combat smoking rates across the State.


Humana’s tobacco cessation VAB does not require any co-payments.


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hrough the HNA, Humana will always know which enrollees smoke and continually engage them to determine if and when they are ready to quit. Following HNA completion, our CM will subsequently call the enrollee to engage them in care, offer a comprehensive smoking cessation assessment, and share information on the health benefits of quitting smoking. We will also mail the assessment and educational materials to enrollees.

Additionally, we have met with and discussed ways in which we can partner with the Louisiana Tobacco Control Initiative (LA-TCI).

Humana also refers enrollees to Louisiana’s free cessation programs: a local PCP counselor within the State’s credentialed provider network as well as the State’s telephonic quit line, an effective mechanism to efficiently reach large numbers of smokers across the State. Humana will identify providers credentialed through the Smoking Cessation Trust and encourage our enrollees to utilize their cessation services without pressuring them to leave their current PCP. In addition to coordinating PCP referrals, Humana will also encourage enrollees to engage in other free tobacco cessation services across the State, including the programs offered through Well-Ahead LA, Quit with Us, LA, and the Louisiana Campaign for Tobacco-Free Living. With a wealth of tobacco cessation resources available, every enrollee will have the tools they need to permanently quit smoking.

To further incentivize quitting, Humana’s mobile wellness and rewards program, Go365, incorporates practices of behavioral economics to encourage enrollees to attend cessation counseling sessions with their PCP and complete healthy activities.


Humana will assess utilization of the tobacco cessation VAB by identifying all enrollees identified as tobacco users via the HNA, and then identify the percent of enrollees ready to quit smoking and the percent of enrollees engaged in covered and VAB.

Continuous evaluation and reporting help Humana ensure that our subcontractors meet quality standards. Our Medicaid Product Development Lead (in coordination with the assigned UM coordinator) provides oversight and monitoring of VAB performance. We present VAB performance data, utilization metrics, and derived outcomes to the Louisiana LMOC meetings. LMOCs comprise consultants to the process (product or process owners), market representatives, corporate Medicaid, product, and UM and decision-makers such as the governance process facilitator and implementation or process improvement leader. The LMOC will assess and review monthly reports drafted by Product Lead on utilization of the smoking cessation VAB against all identified enrollees who are smokers to ensure we notify all eligible enrollees of these services. The Committee will review utilization results, identify trends of high and low utilization, and note possible process improvements. The LMOC also oversees the Provider and Member 360 Committees. The Member 360 Committee will identify process improvement opportunities to ensure the VAB support our enrollees. Our Provider 360 Committee meetings will identify processes to educate and encourage providers to refer enrollees to the VAB.

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6 Vision benefits for adults, including annual exam and glasses or contacts

Humana will expand existing Medicaid coverage in Louisiana to include comprehensive vision services for adult enrollees. In line with the American Optometric Association’s (AOA) policy that vision providers not only take a leading role in eye and vision care, but also in the general health and wellbeing of patients, Humana’s VAB will enable all enrollees to receive vision care at the right time and in the right setting. To improve access to vision services, Humana will cover transportation to and from vision-related appointments for all enrollees.


Adults 21 and over are eligible for Humana’s vision VAB.


Scope: Benefits include the following services up to a $200 allowance per year: • Annual comprehensive eye exams• Annual diabetic retinopathy screening• Necessary repairs to eyeglasses without limitations• Professional services for the evaluation and fitting of contacts• Glasses and/or contacts

For our enrollees that receive covered vision services, Humana will ensure they receive affordable and appropriate care by identifying and coordinating with local organizations, such as federally qualified health centers (FQHCs), community health centers, donated vision service programs, and prominent local eye care provider groups.

Procedure Codes and Description: Vision Services: Procedure codes 92002, 92004, 92012, 92014, V2020, V2100-2199, V2200-2299, V2300-V2399, V2500, V2501, V2511, V2513, V2520, V2521, V2523, V2599

Comparison to Existing LA Medicaid Coverage: We offer preventive vision services and eyewear to adults who do not already receive these as a covered benefit under the Louisiana Medicaid program.


Our vision VAB does not require any co-payments.


Enrollees can access our vision VAB at any point without a referral or prior authorization requirement. We will describe the benefit in all relevant enrollee materials and suggest case management and MSRs discuss it during enrollee interactions. Recognizing the important role that providers play in counseling our enrollees, we will offer provider education on our vision VAB and materials for them to share with our enrollees. For example, enrollees and providers can learn more about vision benefits through welcome calls, a flyer mailed to the enrollee’s home detailing Humana’s VAB, the Enrollee Handbook and Provider Handbook, their CMs, the Humana website, provider training events, newsletters, and at community events, including health fairs and clinic days.

Humana will provide vision services through a subcontracted agreement with Superior Vision. Humana selects subcontractors with long-standing and significant experience in their fields

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Together, Humana and are committed to supporting vision screenings and local wellness events to provide both exams and educational information about the importance of vision examinations for early detection and treatment of chronic conditions, such as diabetes.


Benefit Management Continuous evaluation and reporting helps Humana ensure that enrollees utilize our VABs effectively and that they meet quality standards. Our Medicaid Product Development Lead will coordinate with assigned VAB vendors and effectively manage the relationship. Additionally, we present VAB performance data, utilization metrics, and derived outcomes at the Louisiana LMOC meetings. The LMOC comprises market leadership, SMEs, and corporate partners. It will assess and review monthly reports drafted by Product Lead on utilization of vision VAB against all identified enrollees to ensure we notify all eligible enrollees of these services. The Committee will review utilization results, identify trends of high and low utilization, and note possible process improvements. The LMOC also oversees the Provider and Member 360 Committees.

Subcontractor Management The Subcontractor Oversight team provides monitoring and oversight of all material subcontractors through monthly Subcontractor Performance Summary Reporting. This reporting captures all audit results, performance measure results including LDH performance requirements, status on any open CAPs, and other key issues and opportunities. The team also identifies issues and opportunities meriting review and consideration within the quarterly Subcontractor Oversight Committee meetings and, as appropriate, by the QIC. These meetings will also discuss utilization of vision services and activities to promote access. Humana’s Subcontractor Oversight team and UM team partner to oversee the administration of vision VABs. Together, the teams design utilization measures and reporting details at the onset of the contract and on a regular basis to ensure enrollees are accessing services. We report Superior Vision performance and enrollee utilization of benefits weekly.

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2.10.3.4 For each selected value-added benefit, the proposal should indicate the PMPM actuarial value of benefits assuming an enrollment of 375,000 members, accompanied by a statement from the preparing/consulting actuary who is a member of the American Academy of Actuaries certifying the accuracy of the information.

Table 2.10.3-A: 6 PMPM Actuarial Values

Dental Services Dental Services Biannual $10 Gift Card

Pain Management

Acupuncture Chiropractic Massage Therapy Cognitive Behavioral Therapy Exercise Kit Delivery Gym Membership

Respite Model Medical Respite Bed + Medicaid Flexible Services Fund

Circumcision Circumcision Procedure

Tobacco Cessation PCP Counseling Biannual $25 Gift Card Craving to Quit Mobile Program

Vision Services Vision Services

Actuarial Statement

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Humana Value Added Benefits Louisiana Medicaid Managed Care 2019 RFP

April 12th, 2019 Date

2.10.3.5 The proposal should include a statement of commitment to provide the selected value-added benefits for the entire thirty-six (36) month term of the initial contract and for any extensions, if applicable.

Humana hereby commits to provide the six VAB for the entire 36-month term of the initial Contract and for any extensions.

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dental benefits for adults, including exams, preventive services, and restorative … · 2019. 8....

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